Physiotherapy in bronchiectasis: we have more patients, we need more evidence.

B eyond any reasonable doubt, one of the greatest achievements of medicine in the last century has been the successful reduction of morbidity and mortality due to infectious disease. In 1938, a landmark paper in the Edinburgh Medical Journal by COOKSON and MASON [1] highlighted the high lethality of bronchiectasis even before the fourth decade of life [1, 2]. Thanks to improved hygiene measures and antibiotic treatment, what used to be a fatal disease has now become a chronic disease. The major, scattered lung lesions due to cystic bronchiectasis and often associated with outbreaks of infectious diseases, have given way to smaller, cylindrical bronchiectasis as a consequence of dozens of diseases being able to generate lung damage [3]. However, far from being an extinct disease, bronchiectasis has emerged with force. The ever increasing lifespan of humans, with more people at risk of developing chronic illnesses with potential to bronchiectasis, and the widespread use of imaging techniques (such as chest high-resolution computed tomogra-phy), have increased the burden, particularly in the elderly [4, 5]. But the relevance of bronchiectasis goes beyond its mere presence, as bronchiectasis worsens the prognosis of the generating disease [6] and is associated with an accelerated loss of lung function [7], increased mortality [8] and a significant reduction in quality of life [9, 10]. Notwithstanding the sufferers' individual implications and new epidemiological situation, bronchiectasis still attracts little interest. In 1988, BARKER and BARDANA [11] described bronch-iectasis as an ''orphan disease'' of the airways. However, to date, there is no or little evidence for the effectiveness of most of their treatments, including anticholinergic therapy, inhaled or oral corticosteroids, inhaled hyperosmolar agents, leuko-triene receptor antagonists, short-and long-acting b 2-agonists, methyl-xanthines, mucolytics, and even bronchopulmonary hygiene physical therapy [12]. All these treatments are actually used by extrapolation from success in other diseases with airflow obstruction. However, caution must be exercised as this is not always appropriate and might even be harmful to patients [13]. Therefore, studies with an appropriate level of evidence in bronchiectasis are welcome. The increase in quantity and purulence of sputum viscosity, with retention of broncho-pulmonary secretions characteristic of bronchiectasis, leads to functional airflow obstruction, atelectasis and an increased risk of chronic colonisation of the bronchial mucosa by potentially pathogenic microorganisms , which clouds patients' prognosis [14, 15]. While enrolment in a regular program of chest physiotherapy is considered standard in patients with non-cystic fibrosis bronchiectasis [16, 17], …